1. Council of Governors Performance Report 20 July 2017 meeting
Summary
Committees
NHS Improvement
Quality
Finance
Council of Governors Performance Report
20 July 2017 meeting
Performance for Months 1 & 2 of 2017/18
1.2 NHS Improvement
Segment
1.3 NHS Improvement
Use of Resources
1.1 CQC Rating
Good 1 2 1
Agenda Item: 7
Lead Director: Non-Executive Directors
Presented For: Discussion 1
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2. NHS Improvement Indicators Summary and Recommendations
Committees
NHS Improvement
Quality
Finance
The purpose of this Performance Report is to assist the Council of Governors in seeking assurance against the Trust’s performance and progress in delivery of a broad range of key targets and indicators.
Key Highlights
Slides
NHS Improvement Indicators
Assurance
NHS Improvement indicators have been met for April and May 2017, for those indicators where final data is available.
7 - 8
Quality
Information
Exceptions
The new Friends and Family Test system went live on 1 April The number of reviews completed in April is much lower than in previous months but expected to increase as staff become accustomed to the new system.
Information Governance (IG) training compliance has reduced. As per NHS Digital amended criteria for calculating IG compliance, the Trust included staff who were in date during 2015/16 within the compliance calculation for 2016/17. From April 2017, these have been removed from the figures. Performance is also likely to have been impacted by the decision at the Information Governance Steering Group Meeting to review the staff that were previously classed as exceptions for compliance purposes and to include all staff groups on the Electronic Staff Record. IG training compliance continues to be closely monitored at the business unit performance meetings.
Reasons for and actions to address the reduction in staff receiving appraisal was discussed at the June performance meetings for business units and corporate functions. 10 11
Finance
Control Total Performance – 2017/18 Performance: Surplus/(Deficit) Position: A year to date surplus of £22k compared to a plan deficit of (£665k) gives a favourable £687k variance. A number of Commissioning for Quality and Innovation (CQUIN) requirements and cost improvement plans (CIPs) are profiled to deliver in the latter part of the financial year with some implementation plans still being finalised. CIP and CQUIN delivery therefore remain high risk. The majority of operational pay under spending at May 2017 (month 2) is assessed to be non recurrent with recruitment activities and increased medical locum costs expected. The 2017/18 forecast is that the Trust will meet its Control Total of £826k surplus allowing access to a further £752k Sustainability and Transformation Funding. The executive team agreed to retain a number of financial controls during quarter 1 pending a detailed forecast, risk and efficiency review. 12
Summary and Recommendations
The report shows good performance in May 2017, including further improvement in sickness absence rate, though with under-performance in relation to appraisals and information governance training compliance. Whilst year to date financial performance is good we anticipate elevated financial challenges in quarters 3 and 4 due to phasing of efficiencies and CQUIN targets and as recruitment activities impact.
Correlation of quality information (including patient experience and safety related measures), performance, finance, workforce and health and safety information has taken place at the Board Committees (see highlights at slides 3 to 6). 2
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3. Finance, Business & Investment Committee (Chair: Rob Vincent)
Summary
Committees
NHS Improvement
Quality
Finance
Finance, Business & Investment Committee (Chair: Rob Vincent)
June 2017 Committee Meeting
Assurance
The overall financial position of the Trust is broadly in line with the plan at this early stage in the financial year.
Issues relating to changing shift patterns, bed reductions and corporate service overheads are being pursued with care and quality impact assessments are being carried out with rigour. Additionally, robust and appropriate judgements are being made. Progress will be monitored at future FBIC meetings.
Initial reports were considered on the Digital Strategy and Worksmart programme and, once further developed, will be reported to Board.
The Trust has a determined approach to developing Service Line Reporting arrangements.
The Trust currently meets the tightened national expectations relating to the cost of medical locums.
Exceptions
Issue:
Some elements of the CIP programme are either not fully developed or are likely to provide lower savings in 2017/18 than anticipated.
Status:
Progress monitored through FBIC/Trust Board meetings
March and April 2017 Committee Meetings
Workforce Strategy follow up report to pay particular attention to process and job redesign issues and to any further learning from the Executive’s follow up of issues identified in the Staff Survey
Report to November FBIC.
Community Dental Services contract tender put on hold for 18 months to allow NHS England to undertake wider market engagement. The Trust will utilise this period to prepare for the tendering exercise.
The Trust is investigating the possibility of a collaborative approach with another provider.
Agency Staff Expenditure – the Trust has experienced difficulties in filling some consultant/junior doctor roles due to a lack of psychiatry entrants. At the same time, the Trust is required to ensure agency staff expenditure meets national price wage and expenditure caps.
Agency expenditure was within NHSI price caps for the first period of 2017/18. FBIC will continue to monitor this. 3

4. Quality & Safety Committee (Chair: Sue Butler)
Summary
Committees
NHS Improvement
Quality
Finance
Quality & Safety Committee (Chair: Sue Butler)
Exceptions:
Assurance
From the May and June 2017 Committee meetings:
The Risk Management team challenged the Committee and Board to consider how they had taken forward their approach to risk tolerance and risk appetite and whether they would wish to update their approach.
The Committee wished to see greater improvements than those reflected in the Care Programme Approach clinical audit and agreed to review the reporting of national audits.
Sustaining a system of appropriate implementation of NICE guidelines continues to be a challenge given the volume of guidelines produced by NICE. A robust monitoring system is in place and guidelines are allocated to Business Units for managing through their quality and safety processes.
Governors made a valuable contribution to the content of the Annual Quality Report.
The Quality Governance Improvement Plan has been completed (in response to Monitor).
There has been a significant reduction in the incidents of violence and aggression on inpatient wards and wards receive an early warning when the frequency of specific incidents rise beyond anticipated levels.
The Committee received extensive assurance, via the Safety, Risk and Resilience Annual Report, that robust systems in relation to these areas were in place.
There was no evidence to suggest there had been any underlying systemic issues that connected four serious untoward incidents (SUIs) that had occurred during the last three years.
A robust process was in place to investigate and learn from complaints. The number of complaints was slightly less than in the previous year. Themes that had emerged related to: support for service users, provision of information and attitudes of staff. These themes were also noted by a significant number of other trusts.
Two incidents of staff speaking up had been quickly resolved and work was ongoing to increase awareness of the Freedom to Speak Up Guardian role.
The Children’s Services and Adult Physical Health units continue to have a robust approach to quality and safety management. The Children’s Services unit continues to be successful in obtaining new contracts, including provision to Better Start Bradford over the next five years.
There have been no reportable infections within the Trust’s services. The Trust was the highest achieving Mental Health and Community trust for flu vaccinations.
The Trust has a robust system to manage and sustain resilience.
Good feedback has been received from practitioners and the Safeguarding Board about the integration of Safeguarding for Adults and Children.
Staffing levels within the Medicines Management team are no longer a concern.
An Internal Audit report provided full assurance about the effectiveness of the Quality and Safety Committee
Regular mortality reviews are being undertaken.
Following the recent Cyber Attack, the Committee recommended that a Board service visit be arranged to IM&T. 4

5. Quality & Safety Committee (Chair: Sue Butler)
Summary
Committees
NHS Improvement
Quality
Finance
Quality & Safety Committee (Chair: Sue Butler)
Action
Status
 February and March Committee Meeting Exceptions:
•Triangle of Care initiative extended, due to capacity issues.
To be completed by 31/12/17.
•Psychological Therapies and IAPT to work in a single team on one clinical pathway in order to address psychological therapies waiting time issues
The two teams are now working together under one management structure. The Trust is also recruiting to vacancies in the team in order to address waiting time issues.
May 2017 Committee Meetings Exceptions:
•Committee and Board challenged to consider how they have taken forward their approach to risk tolerance and risk appetite and whether they would wish to update their approach.
Paper developed for consideration by EMT
•Care Programme Approach improvements to be enhanced.
Director of Nursing & Operations overseeing this operational matter.
•Reporting of national audits to be reviewed.
Committee dashboard redesigned in support of reporting requirements
•NICE guidelines to be allocated to Business Units for managing through their quality and safety processes.
Guidelines allocated on a quarterly basis 5

6. Audit Committee (Chair: David Banks)
Summary
Committees
NHS Improvement
Quality
Finance
Audit Committee (Chair: David Banks)
May 2017 Committee Meeting
Assurance
Internal Audit: The committee received twelve `significant assurance’ reports from Internal Audit covering: dental system; IT contracts; payroll/HR; key performance indicators; stakeholder engagement; communications; records management; IAPT; NHSI compliance; consultant job plans; consultant recruitment and e-rostering. The Committee also received `significant assurance’ regarding the Trust’s assurance framework through the `Significant Assurance’ statement in the annual opinion provided by the Head of Internal Audit. There were no `limited assurance’ or `no assurance’ reports.
The Committee also received assurances relating to: counter-fraud activity, losses and special payments, the waiver of standing orders – this is only used where necessary and in accordance with the policy.
External Audit – KPMG confirmed they would be issuing a `clean’ audit report in relation to the Annual Report and Accounts 2016/17. In making this assessment, KPMB confirmed they were supportive of the revaluation of fixed assets by external consultants. The external auditors also confirmed they would be issuing a `clean limited assurance’ report in relation to the Quality Report 2016/17. The `limited assurance’ assessment would be provided due to the limited scope of their work and not because of deficiencies in the Quality Accounts themselves.
Exceptions
There are no outstanding exception items/actions.
The Mental Health Legislation Committee: Next meeting on the 20th July 2017. 6

7. Single Oversight Framework Operational Performance Metrics
Summary
Committees
NHS Improvement
Quality
Finance
Single Oversight Framework Operational Performance Metrics
Indicator M7: Data is provided in relation to the waiting time element of the new standard for Early Intervention in Psychosis (EIP). This shows patients who started treatment in May 2017 within two weeks of referral. The number of incomplete pathways (patients waiting) at the end of May 2017 was 13; 5 of these patients have been waiting for more than two weeks.
Indicator M19: Performance against this standard was assessed as part of the 2016/17 national Commissioning for Quality and Innovation (CQUIN) indicator, via local and national audits in quarter 4 of 2016/17. The local audit of Early Intervention in Psychosis showed 94.0% compliance. The national audit results for inpatient wards and community mental health services were published in June 2017: the Trust performance significantly exceeded the national targets. 7
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8. Single Oversight Framework Operational Performance Metrics
Summary
Committees
NHS Improvement
Quality
Finance
Single Oversight Framework Operational Performance Metrics
Indicator M20a: This Mental Health Services Data Set (MHSDS) data completeness indicator comprises NHS number, date of birth, postcode, gender, GP and commissioner. The Trust is still awaiting clarification from NHS Improvement and NHS Digital about the data definitions to be used to calculate performance. Pending this, data has been provided based on internal calculations from the MHSDS.
Indicator M20b: In January 2017, NHS Improvement confirmed that the MHSDS indicator for priority metrics will only assess performance on three elements – ethnicity, accommodation status and employment status. The Trust is still awaiting clarification from NHS Improvement and NHS Digital about the data definitions to be used to calculate performance for these three elements.
Indicators M21, M10, M11: Within the Single Oversight Framework, Trust performance for Improving Access to Psychological Therapies (IAPT) is assessed quarterly, based on final data published by NHS Digital. 8

9. Serious Incident Numbers
Summary
Committees
NHS Improvement
Quality
Finance
Serious Incident Numbers
Indicator No.
16/17 Out-turn
May 17
17/18 Year to Date Q3 96 1 5 9

10. Service User Experiences
Summary
Committees
NHS Improvement
Quality
Finance
Service User Experiences
Number of Reviews
Nov
Dec
Jan
Feb
Mar
Apr
Adult Physical Health Community
111 87 78 84
110 29
Inpatient Services, Dental and Administration 59 43 27 34 25 2
Mental Health Adults and Community 83 79 92 56 49 30
Nursing, Children and Specialist
160
119
302 47
223 50
Grand Total
413
328
499
221
407
The new Friends and Family Test system went live on 1 April For this month responses are still scored out of 5.
The figures are averages of individual scores. The average score for Inpatient Services has been impacted by only having recorded 2 reviews on the new system. Despite a low average score, both reviewers were “likely to recommend”. Comments offered do not explain the low score. One reviewer said “people were understanding” and the other commented “felt welcomed by staff and patients/need more staff”. The low scores are mapped to a response of “sometimes” (for example “Sometimes I felt involved”). 10

11. Workforce – Appraisal & Mandatory Training
Summary
Committees
NHS Improvement
Quality
Finance
Workforce – Appraisal & Mandatory Training
Indicator No.
Indicator
16/17 Outturn
17/18 Target
Current Performance
17/18 Forecast
Graph
Q17
% Mandatory training (excluding Information Governance Compliance)
88.96%
80%
82.53%
Q17c
% Information Governance Training - All Staff Combined
98.28%
95%
86.78%
Q18
% Staff Receiving
Appraisal
83.77%
77.54%
Q19
% Labour Turnover
11.62%
10%
13.04%
Q20
% Sickness absence rate
5.12%
4.00%
4.69%
Q21
% Vacancy rate
7.17%
8.76% 11

12. Finance Key Measures Summary Committees NHS Improvement Quality
* High risk CIP reserve is £500k meaning a £179k in-year financial risk 12